五姨的第二天！

上周給大家介紹了病例的基本情況介紹在寫作的時候需要注意一些什么，匯總了寫作的要點，并通過實例進行了解析。有需要的搜標題回看：Case report（二）如何寫并成功發(fā)表，通過案例分享給臨床科研者們一點啟示

如何寫好一篇case report并成功發(fā)表，通過案例分享給臨床科研者們一點啟示Part1。今天，我們再對病程、檢查和診斷部分的寫作進行一個詳細的剖析。

現階段疫情又來勢洶洶，襲擊了全國各地，我國當前面臨的疫情形勢十分嚴峻，大家在進行臨床工作的時候挖掘下周邊的病例是否就可以寫成case發(fā)表一下呢？

2?病程

主要說明典型的癥狀、并發(fā)癥、診斷與治療過程，避免無關的材料。

例2-1：出自Ilgüy D, Ilgüy M, Fisekcioglu E, Bayirli G (2014) Detection of jaw and root fractures using cone beam computed tomography: a case report.

The patient was initially examined by her dentist, who diagnosed a fracture in the right mandibular canine region with CT (初步診斷). Upon clinical examination, the right mandibular canine did not respond to an electric pulp sensitivity test or to a cold sensitivity test at 50?C. The tooth was not mobile, but was sensitive to percussion. The adjacent teeth were asymptomatic and responded normally to cold and electric pulp tests.

解析：介紹整個疾病的診斷過程及發(fā)現。最初由牙醫(yī)通過CT診斷為右下頜犬區(qū)域骨折，隨后臨床檢測發(fā)現右下頜犬區(qū)域對電漿敏感性測試或冷敏感性試驗無反應。牙齒無松動，但對叩診敏感，相鄰牙齒無任何癥狀且對電漿敏感性測試或冷敏感性試驗有反應。

例2-2：出自Sjogren PP, Banerji N, Batts KP, Graczyk MJ, Dunn DH (2013) Rare presentation of a gastrointestinal stromal tumor with spontaneous esophageal perforation: A case report. International journal of surgery case reports 4 (7):636-639.

After resuscitation and stabilization, a diagnostic chest radiograph?revealed?a moderate right-sided pleural effusion that was drained via tube thoracostomy with an output of 1200 mL serosanguineous fluid. A subsequent esophagram?demonstrated?a perforation proximal to an elongated stricture in the distal esophagus.

????解析：介紹診斷過程。首先胸片顯示右側胸腔積液，經管狀胸廓造口術引流后，隨后的食管x線片發(fā)現食道遠端有細長的穿孔現象。

3?檢查與診斷

主要是說明特殊的檢查方法及結果，這個也是病例報告與其他文章的不同之處，即方法和結果一起描述，表示某種方法得出某種結果。

例3-1：出自Gugssa SA, Johnston JC (2012) Syphilitic aortic aneurysm with spastic paraparesis: A novel presentation and review of the literature. Journal of the neurological sciences 323 (1):241-244.

On?general examination (一般檢查), he had systolic hypertension with wide pulse pressure and a grade II early diastolic murmur at the left lower sternal border.?Breath sounds?(呼吸音檢查) were clear bilaterally. There were no carotid bruits.?Abdominal examination?(腹部檢查) was normal to auscultation and palpation. Femoral, tibialis posterior and dorsalis pedis pulses were normal.

????解析：本段介紹一些初步的常規(guī)檢查檢查及判斷，患者有收縮性高血壓，呼吸音清晰，無頸動脈雜音，腹部聽診及觸診也是正常的，另外股骨、脛后和足背動脈搏動也是正常的。這部分寫作要注意的是，并非所有做過的常規(guī)檢查都要寫，關鍵是看文章所介紹疾病，與其相關的檢查必須描述。

例3-2：出自Toriyama A, Ishida M, Amano T, Nakagawa T, Kaku S, Iwai M, Yoshida K, Kagotani A, Takahashi K, Murakami T (2013) Leiomyomatosis peritonealis disseminata coexisting with endometriosis within the same lesions: a case report with review of the literature. Int J Clin Exp Pathol 6 (12):2949-2954.

Physical examination?(體格檢查) revealed an immovable tumor in her abdominal cavity.?Laboratory tests?(實驗室檢查) demonstrated elevated serum CA125 (567 U/mL; range <34) and CA19-9 (193 U/mL; range <36) levels.?Contrast enhanced computed tomography?(CT掃描檢查) showed a containing solid area with enhancement in the right ovary and multiple small nodules with enhancement in her abdominal cavity.?Intraoperative examination?(術中檢查)?revealed that the right ovarian tumor, measuring 12 cm in diameter, was strongly adhered to the cecum, and innumerable small nodular lesions, measuring 1 to 30 mm in diameter, were present in the mesentery, omentum, peritoneum, Douglas’s pouch, and serosal surface of the small intestine, large intestine, and rectum.?Histopathological examination?(組織病理學檢查) of the resected disseminated nodules revealed well-circumscribed multiple nodular lesions, measuring 1 to 25 mm in diameter, in the peritoneum。

解析：本段對疾病的診斷方法及結果做了詳細描述。首先體格檢查結果顯示腹腔有腫瘤，實驗室血液檢查發(fā)現血清中疾病相關因子的水平升高。然后，CT檢測發(fā)現腹腔有囊性病變。隨后的手術中檢測發(fā)現右卵巢腫瘤粘附在盲腸上，且在其他腸中伴有無數的結節(jié)狀病灶。最終的組織病理學檢查病灶發(fā)現彌散性的結節(jié)。疾病的檢查和診斷這部分是文章重點，需要詳細描述，要讓讀者明白整個過程，可以為其他臨床醫(yī)生提供一些借鑒和指導。

我們擅長：生信分析、醫(yī)學統計、論文潤色、科研作圖、期刊推薦、基金申請指導&meta分析思路etc.科研事宜，歡迎來撩！